Unit 3 - Gout & Dietary Modifications

Question 1

Gout:

Answer 1

common & painful arthritic condition, which is related to the metabolism of purines (adenine and guanine), hypoxanthine, and xanthine, derived from foods or deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) of tissues. is related to the metabolism of purines

Question 2

What is Gout?

Answer 2

an inflammatory disease of the joints; it develops when monosodium urate crystals deposit within joints, due to high concentration of uric acid in blood (hyperuricemia) and synovial fluid.

Question 3

Where on the body does Gout affect?

Answer 3

It often affects one joint. However, it may affect two or more joints. The joint commonly affected is the first metatarsal phalangeal joint (MTP) (first joint of the big toe)

Question 4

What is the epidemiology of Gout?

Answer 4

• One of the most common inflammatory arthritic disease.
• It is more common in males than in females.
• Most patients (approximately 90%) are men older than 30 years of age.
• Women are mostly affected post-menopausal.
• The higher risk of gout in men may be due to the effects of estrogen on renal clearance of uric acid.
• Children, young adults, and pre-menopausal women are not known to develop gout.
• The prevalence of gout increases with age, and it is estimated to affect 1-4% of the general population worldwide.

Question 5

What is the etiology & clinical manifestation of Gout?

Answer 5

• The hyperuricemia that precedes gout is caused by the accumulation of excess uric acid in serum.
• Uric acid is the breakdown product of purines (adenine and guanine nucleotide bases) from DNA, RNA, or foods (Figure 2), which cannot be excreted fast enough from the body than is being produced.
• Increased production of uric acid is seen in cases of chemotherapy, radiation therapy, (Lesch-Nyhan HGPRT deficiency) syndrome, and excessive cell turnover in tumors.
• In contrast, acidosis, renal disease, nonsteroidal anti-inflammatory drugs (NSAIDs) drugs, and diuretics cause decreased renal excretion of uric acid.

Question 6

What are the salvage pathway enzymes of Gout?

Answer 6

Adenosine phosphoribosyl transferase (APRT) and hypoxanthine /guanine phosphoribosyl transferase (HGPRT) are both salvage pathway enzymes.

Question 7

What can patients with Gout be treated with?

Answer 7

Patients with gout can be treated with the drug allopurinol, which is essentially an inhibitor of the enzyme xanthine oxidase.

Question 8

What does the excess uric acids lead to?

Answer 8

The excess uric acids lead to the formation of monosodium urate crystals, and eventual deposition of the crystals in the joints. The monosodium urate crystals, in or around joints, interact with dendritic cells and macrophages, leading to phagocytosis of the urate crystals and triggering the release of pro-inflammatory cytokines, and ultimately inflammation involving activation of caspase and interleukin-1 beta.

Question 9

What is the acute sx of Gout?

Answer 9

The acute symptom of gout, known as gout “flare”, develops suddenly with severe joint pain and swelling, shiny red skin and tenderness around the joint. It can last for hours. Sometimes, it can disappear within days without treatment.

Question 10

What happens when Gout is untreated over a period of years?

Answer 10

Untreated gout over a period of years, chronic hyperuricemia, can result in the steady deposition of uric acid crystals in the joints and in the soft tissues surrounding the joints, which form large deposits called tophi that looks like lumps under the skin.

Left untreated permanent joint damage and disability can occur in individuals.

Question 11

Apart from the MTP joints, what else is affected?

Answer 11

Apart from the MTP joints, the ankles, knees, elbows, wrist, fingers, and tendons are also affected.

Question 12

How is Gout diagnosed?

Answer 12

Gout is diagnosed by microscopic identification of needle-shaped monosodium urate crystals in aspirated synovial fluid (gold standard test). These crystals are negatively birefringent under polarized light microscopy, where they appear yellow in color.

Question 13

Often, patients experience hyperuricemia without gout symptoms (asymptomatic hyperuricemia) for a long time, and sometime years, and suddenly, there is a trigger leading to gout attack. The triggers are:

Answer 13

1. Surgery or trauma
2. Diet
3. Cold temperature
4. Stress
5. Extreme physical exertion
6. Medications

Question 14

The underlying mechanism of gout is associated with risk factors that are patient-related factors. These risk factors are:

Answer 14

1. MALE GENDER. Males are more likely than females to have gout.
2. OLDER AGE. As the person gets older risk of developing gout increase.
3. DIETARY SOURCES. High purine intake through food and alcohol can increase the risk of
   gout by raising uric acid.
4. MEDICAL CONDITIONS. Obesity, diabetes, hyperlipidemia, congestive heart failure, chronic kidney disease, and hypertension are all associated with increased risk of gout. Some of these conditions are related to dietary factors and decrease in renal excretion of gout.
5. MEDICATIONS. Some medications such as aspirin, NSAIDs, cyclosporine, diuretics, and ethambutol have been associated with hyperuricemia and increased risk of gout.
6. GENETICS. Certain genes have been discovered to be associated with hyperuricemia and risk of gout. Genome-wide association studies, using serum urate levels as the outcome, involving 110,000 individuals discovered several (28-urate-associted) variant loci. Genes that encode renal and gut uric acid transporters (SLC2A9/GLUT9, ABCG2) dominate these loci

Question 15

What about lifestyle modifications?

Answer 15

Urate lowering therapies are used to treat gout. However, lifestyle modifications, such as dietary change, may help to reduce the risk of recurrence of gout flares. Dietary change without urate lowering therapies cannot be used to treat gout.

Question 16

The following lifestyle modifications can help to reduce the risk of hyperuricemia:

Answer 16

1. Weight loss.
2. Hydration.
3. Reduce alcohol consumption.
4. Reduce purine intake

Question 17

What about non-pharm management?

Answer 17

All patients with gout can benefit from non-pharmacologic management of their symptoms with focus on education, diet, lifestyle modifications, and screening for other associated diseases or comorbidities. Diet alone cannot be adequate to treat gout. Therefore, it should be considered as an adjunct to pharmacological treatments to prevent delay in the lowering of serum uric acid level. The main aims of diet and lifestyle modifications in gout are the promotion and maintenance of health and preventative care through effective management of patients.

Question 18

What about dietary intervention?

Answer 18

• Food is responsible for approximately 30% of the uric acid content in the blood.
• It is established that diet is very important to those who wish to lower their serum uric acid levels.
• The amount of purines in foods usually correlate with the amount of serum uric acid.
• However, other considerations should not be overlooked, such as extreme physical exertion or traumatic injuries that may contribute to the occurrence of gout.

Question 19

In addition, __________ intake can correlate to higher purine intake through meat, increased risk of co-morbidities that increases gout risk.

Answer 19

high saturated fat

Question 20

Essentially, foods that affect serum uric acid can be broadly classified into three categories:

Answer 20

1. Foods to Limit
2. Foods to Emphasize
3. Foods to Enjoy Moderately as Part of a Nutritious Diet

Question 21

1. Foods to Limit:

Answer 21

These are usually foods with high purine content that increase the risk of gout flares or hyperuricemia, such as:
* WILD OR FARMED GAME (pheasant, quail, grouse, rabbit/hare, venison).
* ORGAN MEATS (kidney, heart, sweetbreads, liver, pate, terrine, liver sausage, liver of a duck or goose/foie gras).
* EXTRACTS OF MEAT AND YEAST (bovril, oxo, marmite, vegemite).
* MEAT (red meats, beef, pork and lamb). Adjust daily meat, fish, shellfish intake to 3-6 oz
daily to reduce purine intake.
* FISH ROE (cod roe, caviar, and taramasalata).
* SHELLFISH (scallops, herrings, mackerel, clams, mussels, trout. crayfish, shrimp, and
lobster) Adjust daily meat, fish, shellfish intake to 3-6 oz daily to reduce purine intake.
* SMALL FISH-WHOLE OR PROCESSED (anchovies, sardines, sprats, whitebait, anchovy paste, men’s relish, Thai fish sauce). Adjust daily meat, fish, shellfish intake to 3-6 oz daily to
reduce purine intake.
* ALCOHOL intake is strongly associated with an increased risk of gout. This risk varies substantially according to type of alcoholic beverage: beer confer a greater risk than spirits (whiskey and vodka).

Question 22

2. Foods to emphasize:

Answer 22

These foods usually have lower purine content, which may decrease the risk of gout or may protect against gout flares. The following foods may be enjoyed regularly as part of a nutritious diet:
* FRUIT. In addition, there is some evidence cherries can reduce gout risk. The fructose in whole fruits unlike sugar-sweetened beverages (pop, juice) and high fructose corn syrup does not induce hyperuricemia.
* NUTS have lower purine content and are a plant-based source of protein for patients with gout. Some inclusion can help with reducing reliance on meat for protein. Not peanuts or cashews, and preferably not salted nuts
* DAIRY PRODUCTS. An inverse relationship has been observed between dairy consumption and risk of hyperuricemia or gout. Examples include milk, creams, yogurt, ice cream, cheese, eggs, bearing in mind the high fat content of some dairy products.
* VEGETABLES include runner/green/string beans, French beans, mange-tour, and sugar snap peas. All vegetables can help to reduce chronic disease associated with gout. Encouraging intake at meals can also help with mindful meat portions.
* NON-CAFFEINATED COFFEE. An inverse relationship has been found between consumption of non-caffeinated coffee and the risk of hyperuricemia/gout.
* KEEP WELL HYDRATED. Enjoy at least 8 cups of fluid per day. Emphasize water in addition to non-caffeinated tea and coffee.

Question 23

3. Foods to enjoy moderately as part of a nutritious diet:

Answer 23

Some of these foods have higher amounts of purines. However, as part of a nutritious diet they do not seem to increase the risk of gout.
* Breads, cereals, grains, and starches such as rice, pasta, potato, corn. Cereals. B
* Spinach, asparagus, avocado, and mushrooms, Brassicas including cauliflower,
broccoli, calabrese, kale, Brussels sprouts, and “Chinese greens”.
* Poultry. Examples include chicken, duck, turkey, and goose. Adjust daily meat,
fish, shellfish intake to 3-6 oz daily to reduce purine intake. Lentils, soya bean
curd, tofu, tempeh, miso, hummus, peas and beans (including chickpeas).
* Oysters, prawns, and scampi.
* Wine. In contrast to beer and spirits, moderate wine consumption (<7 glasses of
wine/week), due to its polyphenols content (compounds with antioxidant properties), does not seem to act as a factor influencing the prevalence of gout.

Question 24

What are the Dietary Patterns?

Answer 24

There are challenges in adherence to intake of diets low in purine for gout care. A lower purine diet may include smaller portions of meat than usual, which can be a big change for many patients. Therefore, patients may naturally increase consumption of refined carbohydrates. There is a need for effective dietary alternatives to address both the burden of gout and its associated metabolic comorbidities. The Dietary Approaches to Stop Hypertension (DASH) diet and the Mediterranean diet (MedDiet) have been shown to reduce serum urate levels and the risk of gout and are an appropriate preventative approach for those with hyperuricemia at increased risk of developing gout. Both eating styles emphasize fresh foods including fruit and vegetables, whole grains, and moderate protein.

Question 25

DASH diet:

Answer 25

The DASH diet emphasizes intake of fruits, vegetables, low fat dairy foods, and reduced saturated and total fat. Several studies have reported that it is associated with a lower risk of gout, suggesting that its effect of lowering uric acid levels in individuals with hyperuricemia translates to a lower risk of gout.

Question 26

MedDiet:

Answer 26

The MedDiet is a traditional dietary pattern that includes a proportionally high consumption of unrefined cereals, legumes, fruits and vegetables, and olive oil, with moderate consumption of fish, dairy products such as cheese and yogurt, and wine, and low consumption of meat, meat products, and sweets. It is often cited as beneficial for obesity, diabetes, and coronary heart disease. Several studies have established an inverse relationship between the MedDiet and serum uric acid levels. Therefore MedDiet is more likely to lower the risk of gout than Western-type diet (high ultraprocessed of red and processed meats, refined grains, sweets, and desserts). However, it is important to know that effect of MedDiet on the incidence for gout has not be established.

Question 27

What are the long-term effects of dietary management?

Answer 27

In general, adherence to medication is low in gout patients and adherence to dietary recommendations tend to be even lower. This may be an important challenge to consider when promoting dietary change. This also highlights the value in discussing gradual lifestyle change for health and potential gout benefit rather than significant, difficult to maintain restrictions in diet. While diet is an important modifiable factor, in the long-term, it may have less of a direct role in changing the serum urate levels than previously thought. Nevertheless, we should still promote overall health through diet, and utilize it in conjunction with urate-lowering therapy in minimizing the burden of disease.

Unfortunately, even with dietary management, drug therapies and lifestyle modifications, a majority of patients will continue to have gout attacks at least once a year that can last for months, with comorbidities such as obesity, diabetes, hyperlipidemia, congestive heart failure, chronic kidney disease, and hypertension.

Question 28

What is the conclusion of Gout?

Answer 28

Medications are the predominant mode of treatment for gout, nutritional therapy and lifestyle- modifications may not be consistently recommended. Nevertheless, it may still be helpful in managing gout to include recommendations for moderate alcohol consumption, avoiding purine- rich foods, and maintaining a healthy body weight.